Nokea
A patient who is in renal failure partially loses the ability to regulate changes in pH because the kidneys:
- A. Regulate and reabsorb carbonic acid to change and maintain pH
- B. Buffer acids through electrolyte changes
- C. Regenerate and reabsorb bicarbonate to maintain a stable pH
- D. Combine carbonic acid and bicarbonate to maintain a stable pH
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which of the following might the nurse assess in a patient diagnosed with hypermagnesemia?
- A. Diminished deep tendon reflexes
- B. Tachycardia
- C. Cool clammy skin
- D. Increased serum magnesium
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:
- A. Daily weight
- B. Serum sodium levels
- C. Measured intake and output
- D. Blood pressure
Correct Answer: A
Rationale: Daily weights show trends and can assist medical management by indicating if interventions and medications are effective. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the patient with fluid balance problems. However, if a patient is dehydrated, some laboratory data can show false elevations. Intake and output is extremely important, but matching the two is difficult because fluid is also lost through breathing, perspiration, stool, and surgical tubes. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by either depletion or excess of fluids in some situations.
The patient asks the nurse if he will die if air bubbles get into the IV tubing. What is the nurse's best response?
- A. The system is closed and that is impossible.
- B. Only relatively large volumes of air administered rapidly are dangerous.
- C. There is a risk of complication with IV administration.
- D. You watch too many movies.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:
- A. Hypophosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hyperkalemia
Correct Answer: B
Rationale: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and less commonly in the feet. Taking a normal blood pressure could illicit a carpal spasm if it creates slight ischemia of the ulnar nerve.
A nurse sees a variety of patients in the community health clinic. Which of the following patients would be at the greatest risk of dehydration?
- A. An 18-year-old basketball player with a stress fracture of the right foot
- B. An infant with diarrhea
- C. A 45-year-old with stomach flu
- D. An elderly patient living alone
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.